Kate Johnson

May 27, 2012

May 27, 2012 (Philadelphia, Pennsylvania) — Super intensive exercise-based weight-loss programs shed pounds and reduce the risk for diabetes and other cardiovascular risk factors, but the medical community resists this approach, according to the medical advisor on reality TV's Biggest Loser.

"We have to teach people what exercise is. We have to teach doctors what exercise is because, unfortunately, there's a bias in doctors against vigorous exercise," said Robert Huizenga, MD, during a press conference here at the American Association of Clinical Endocrinologists 21st Annual Meeting and Clinical Congress. Dr. Huizenga runs a private internal medicine practice in Beverly Hills, California, and is associate clinical professor of medicine at the University of California at Los Angeles.

"If we get away from dumbed-down exercise recommendations, we could see a whole new paradigm for treating type 2 diabetes," he said later during the scientific session.

In a retrospective analysis of 35 contestants, Dr. Huizenga showed how an "exercise-centric" program with only minor dietary restrictions resulted in a mean weight loss of 51.8 kg (36% of body weight) at 29 weeks, and mean reduction in body mass index of 17.1 kg/m² (from a mean baseline of 46.4 kg/m²).

"We had some radical ideas when I was asked in 2003 what to do with a weight-loss show," said Dr. Huizenga. "The preponderance of experts in this country recommend an "attainable" [weight loss] goal of 5% to 10%. We don't believe that."

Dr. Huizenga and his team also do not believe that following current exercise guidelines is helpful. Morbidly obese contestants entering the show are gaining an average of 15 pounds per year doing the recommended 20 minutes of exercise a day, he said. The Biggest Loser program boosts their workouts to 3.7 hours daily — "2 hours vigorous and 2 hours moderate — which is walking," he explained.

Dietary interventions are moderate, he told Medscape Medical News. We aim for calories at 80% of their calculated resting daily energy expenditure, a mix of 30% protein, 25% fat, and 45% of calories as low-glycemic carbohydrates."

Of the 35 study subjects, 50% were either prediabetic (n = 12) or diabetic (n = 6) at baseline, which is a consistent pattern among contestants on the show. "Probably two thirds do not know this when we first see them," he noted.

In addition, 77% of participants were hypertensive and 46% were on antihypertensive medications at baseline, he said.

By week 2 of the show, all participants were off their antihypertensive medications; by week 5, all diagnostic criteria for prediabetes, diabetes, and hypertension had disappeared, he reported.

Specifically, mean systolic blood pressure dropped from a baseline of 138 to 118 mm Hg by week 29, and diastolic blood pressure dropped from a baseline of 90 to 74 mm Hg.

Glycated hemoglobin dropped from a baseline of 5.6% in the prediabetes group and 6.9% in the diabetes group to 5.1% and 5.2%, respectively.

Fasting glucose dropped from a baseline of 82 to 79 mg/dL in the prediabetic group, and from 129 to 91 mg/dL in the diabetic group.

Overall, mean fasting insulin fell from 14.1 to 5.5 µgIU/mL, mean homeostasis model assessment estimated–insulin resistance (HOMA-IR) score fell from 2.1 to 0.5, mean serum adiponectin levels rose from 8.6 to 13.1 µg/mL, and mean triglycerides fell from 127 to 65 mg/dL.

Such rapid and significant outcomes definitely require patient motivation, said Dr. Huizenga, but that alone is not enough.

"We believe that current education is insufficient. We believe the current evaluation of sleep, of psychiatric issues, the dietary approach, and the fact that there's not a sports-medicine team behind these people trying to lose weight is incorrect," he said.

Contestants on the show receive multidisciplinary support that is, ironically, far from "reality" for the average obese American.

"There's not a system in this country...in which we can duplicate what we do on this reality show," he said. "It's very sad because we know it works, but we need a much more intense team around these individuals. When you exercise, you are going to get injuries; you need a sports team around you. And you can't exercise if you have obstructive sleep apnea, or depression, or your family situation isn't right — so you need a system to address a lot of things."

Citing an "urgent need for development, implementation, and payer coverage of aggressive exercise-centric programs for the prevention and remission/cure of type 2 diabetes, hypertension, and their associated comorbidities," Dr. Huizenga said that "it's time we rethink diabetes. There is another way."

Questions and comments from meeting delegates immediately underscored the medical skepticism that sometimes accompanies lifestyle interventions for obesity.

"I appreciate all your great data, but until you show something 2 or 3 years down the road, one should be a little cautious," said Lewis Braverman, MD, professor of medicine in the Department of Medicine at Boston University School of Medicine in Massachusetts.

Other delegates expressed doubt that regular patients, without the motivation of a reality TV competition, will find the motivation required for such weight loss.

"The problem with lifestyle is that in most practitioners' hands it's been less than successful," said Alan Garber, MD, PhD, moderator of the session and professor of medicine at Baylor College of Medicine in Houston, Texas. "We're dealing with a preselected or self-selected group that has applied for entrance to the show and is obviously motivated to comply with the program," he told Medscape Medical News.

"It's clear that with a motivated population, such an intervention has excellent potential. What we need to ascertain is what fraction of the obese population is that motivated.... I think it's the minority, and it may well be a rather small minority."

In addition, he said, such interventions are usually impractical to deliver. "It's a very intensive program; it requires a lot of midlevel practitioners and allied health professionals to make this work.... To do it well is expensive. It is not cheaper than prescription medicines, and probably not cheaper than doing a modest bariatric surgical intervention."

However, Dr. Garber is less inclined than Dr. Braverman to dismiss the data.

"We really only have brief follow-up on bariatric surgery — most of the studies have only 2 years of follow-up.... I would really like to have more data before someone takes this overly enthusiastic or pessimistic view of any of these interventions. We need a better idea about the durability of the effect."

Dr. Huizenga reports being an advisor to the Biggest Loser. Dr. Garber and Dr. Braverman have disclosed no relevant financial relationships.

American Association of Clinical Endocrinologists (AACE) 21st Annual Meeting and Clinical Congress: Abstract 1330. Presented May 25, 2012.

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